Documente Academic
Documente Profesional
Documente Cultură
Alice King,1,2 Judith J. Stellar,3 Anne Blevins,1 and Kara Noelle Shah1,4,5,*
1
Pediatric Advanced Wound and Skin Services, and Divisions of 2Pediatric General and Thoracic Surgery and
4
Dermatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.
3
Department of Nursing, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania.
5
Departments of Pediatrics and Dermatology, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Premature neonate
Impaired epidermal barrier
Increased transepidermal water loss and electrolyte imbalance
Skin fragility and increased risk of epidermal stripping
Increased percutaneous absorption of topical agents due to increased body
surface area to weight ratio (e.g., alcohols, povidone-iodine)
Susceptibility to irritants
Impaired thermoregulation
Immature immune system
Term neonate
Skin fragility
Increased percutaneous absorption of topical agents due to increased body
surface area to weight ratio
Susceptibility to irritants
Impaired thermoregulation
Immature immune system
Infant
Increased percutaneous absorption of topical agents due to increased body Figure 1. Optimal product choice for local wound care based on depth of
surface area to weight ratio injury and amount of exudate.
May attempt to remove dressings
May contaminate wound and dressings, including the diaper area
Need to place dressings securely due to crawling, running, and playing
Fear, anxiety, and pain may complicate wound care and dressing changes
that may interfere with wound healing. Manage-
Child
ment of the wound is a dynamic process, and the
May attempt to remove dressings astute clinician should frequently reassess the
May contaminate wound and dressings wound with regard to wound bed factors, including
Need to place dressings securely due to running and playing the depth of injury and amount of exudate, and
Fear, anxiety, and pain may complicate wound care and dressing changes,
in particular with removal of adhesive dressings (‘‘tape phobia’’)
with regard to the overall patient condition and
Need for developmentally appropriate preparation for wound care and modify the use of wound care dressings and other
dressing changes, including use of child life specialists and caregivers products as needed (Fig. 2).
to provide psychological support and distraction Wound care products and dressings have
Neurodevelopmental delays may further complicate wound care
evolved dramatically from the use of simple wet or
dry gauze to highly specialized skin care products
also include neurodevelopmental and behavioral (Table 2). Although the use of wet-to-dry gauze
considerations. dressings is still a common practice in wound care,
Fortunately, in the majority of otherwise heal- the use of wet-to-dry gauze has been shown to
thy children, wound healing is brisk, uncompli- cause nonselective mechanical debridement of the
cated, and requires minimal specialized attention.
Chronically ill children, however, in particular
those with limited mobility, poor nutritional sta-
tus, immune compromise, neurodevelopmental
delays, and/or frequent hospitalization are predis-
posed to poor wound healing and iatrogenic skin
injury.
Wound healing is a complex, dynamic process
that involves four basic phases: coagulation and
hemostasis; inflammation; proliferation and re-
pair; and wound maturation and remodeling.14 As
such, the use of specific wound care products by
necessity may need to be adjusted during the
wound healing process (Fig. 1). Optimal product
choice is dependent on several factors: the type of
wound present; the overall condition of the patient,
including any relevant comorbidities; and the
condition of the wound bed, including the presence
Figure 2. Considerations in dressing and product choice based on the
of infection, excessive granulation tissue, or the
different phases of wound healing.
presence of devitalized tissue (slough or eschar)
DRESSINGS AND PRODUCTS IN PEDIATRIC WOUND CARE 327
wound that results in injury to normal tissue, re- Wound management issues in pediatrics
sults in desiccation of the wound bed, and is asso- Pressure ulcers. Pressure ulcers are common in
ciated with periwound maceration and increased hospitalized neonates, infants, and children, with
pain during dressing changes; in addition, use of estimates of point prevalence ranging from 10%
wet-to-dry gauze dressings has been associated to 35%, and they are most common in patients
with increased cost and labor due to need for more requiring management in an intensive care
frequent dressing changes and with an increased unit.18,22,23 The most common sites for the devel-
risk for infection.15 Alternative, less painful op- opment of pressure ulcers in neonates and children
tions for selective debridement include use of oc- related to immobility are the sacrum/coccyx (most
clusive dressings to promote autolysis, use of common site in children), occiput (most common site
hydrogels, and enzymatic debridement. Use of ap- in infants), and heels.24 More than 50% of pressure
propriate wound care products and dressings help ulcers in hospitalized children are related to pres-
to maintain an optimal wound healing environ- sure from devices and equipment, including blood
ment by maintaining adequate moisture, humid- pressure cuffs; tracheostomy cannulas, connectors,
ity, pH, and temperature, by minimizing pain, and and tubing; oxygen delivery devices such as nasal
by preventing damage to the skin surrounding the prongs, noninvasive positive pressure ventilation
wound such as epidermal stripping and maceration interfaces, and continuous positive airway pressure
as well as to address issues such as delayed wound masks; and cutaneous oximetry probes.25 In chil-
healing due to complications such as bacterial in- dren, pressure ulcers related to medical devices are
fection, necrotic devitalized tissue, exudate, and seen most frequently on the head and neck in as-
slough. Use of specialized wound care dressings sociation with the presence of a tracheostomy or
may also require less frequent dressing changes. noninvasive positive pressure ventilation interface,
However, overall data on the use of these prod- on the torso in association with placement of elec-
ucts even in adults are extremely limited, with a trocardiography leads, and on the digits in associa-
recent assessment of published randomized con- tion with use of pulse oximeter probes.2,3,26
trolled trials, meta-analyses, and cost-effective- The Braden Q Scale and Modified Braden Q Scale
ness studies providing only weak levels of clinical were developed to allow for standardized assess-
efficacy.16 ment of pressure ulcer risk in pediatric patients.
There are currently only a limited number of These scales are based on assessment of mobil-
published clinical guidelines for the evaluation and ity, activity, sensory perception, moisture, friction/
management of wounds in the neonatal and pedi- shear, nutrition, and tissue perfusion/oxygenation
atric populations.2,13,17–21 None of these have un- (Fig. 3B) and help to identify pediatric patients
dergone the rigorous assessment required for the requiring care in a pediatric intensive care unit
generation of evidence-based guidelines. As such, who are at risk for the development of pressure
wound care practices and selection of wound care ulcers.27,28 Prevention of pressure ulcer development
products tend to reflect provider experience and is a major nursing initiative, and is dependent on
preference.1 Given these constraints, the authors comprehensive and frequent patient assessment
have utilized a combination of literature review and pressure distribution in at-risk areas through
and personal experience on which to base a the use of interventions such as appropriate pad-
thoughtful discussion of the use of dressings and ding of bony prominences and devices that come in
other wound care products in the neonatal and contact with the skin; use of age-appropriate spe-
pediatric populations with an emphasis on the cialty mattress such as an alternating pressure
management of pressure ulcers, epidermal strip- mattress, low-air loss, or foam or gel overlay; fre-
ping, surgical wounds, MASD, and intravenous quent repositioning; and frequent assessment and
extravasation injury and on the use of NPWT. rotation, when possible, of medical devices.1,10,29
Basic information on types of dressings, examples Unfortunately, despite use of appropriate preven-
of specific products often used in neonates and tative measures, pressure ulcers may still occur.
children, indications for use, and special consider- The most commonly used dressings in the man-
ations/cautions with use is presented in Table 2. A agement of pressure ulcers in the pediatric popu-
discussion of other wound care strategies, includ- lation include hydrocolloids, hydrogels (available
ing use of bioengineered skin substitutes, and of as amorphous gel and sheets), polyurethane foams,
wound care for specialized population such as pa- and transparent films.30,31 In addition, NPWT is
tients with epidermolysis bullosa, toxic epidermal also used in the management of Stage III and Stage
necrolysis, cutaneous graft versus host disease, or IV pressure ulcers. Medical device-related pres-
burns, is beyond the scope of this article. sure ulcers is a challenge in neonates and children
328 KING ET AL.
Table 2. Wound care products commonly used in neonates, infants, and children
Transparent May contain Skin tears Prevents wound Semipermanent; not Tegaderm
polyurethane film adhesive Superficial wounds with contamination intended for frequent Opsite
little to no exudate Provides moist wound dressing changes
Secondary dressing healing May result in epidermal
Secure devices to skin Promotes autolytic stripping (if adhesive
debridement present)
Nonabsorptive
Contact layer Some contain soft- Superficial tears Prevents wound Requires secondary Mepitel
silicone adhesive Superficial wounds with contamination dressing Mepital-One
little to no exudate Provides moist wound N-TERFACE
First- and second-degree healing Restore Contact
burns Allows transfer of Restore Contact Silver
Minimal to moderate exudate into Versatel
exudative wounds absorbant dressing Adaptic
Pressure ulcers Nonabsorptive Xeroform
Partial and full-thickness Conformant Wound Veil
wounds
Hydrocolloid (gelatin, May contain Minimal to moderate Prevents wound Caution in infected Duoderm
pectin, and/or adhesive exudative wounds contamination wounds Tegasorb
carboxymethyl Pressure ulcers Promotes autolytic May cause maceration Medihoney
cellulose) Partial and full-thickness debridement of periwound
wounds Minimal absorption May result in epidermal
Promotes autolytic Ease of use stripping (if adhesive
debridement present)
Pressure redistribution
Polyurethane foam and May contain Moderate to heavy Ease of removal (only if Not for use in dry Polymema
composite adhesive exudative wounds nonadherent or wounds Allevyn
Partial and full-thickness containing soft Requires a secondary Lyofoam
wounds silicone adhesive) dressing (unless Mepilex
Peristomal Ease of use compositie) Mepilex-Ag
Pressure redistribution Moderate absorption Hydrosorb
Infected woundsb Pressure redistribution
Comfortable
Hydrogel Nonadherent Minimal exudate or dry Pressure redistribution May over-hydrate Sheet:
wounds Reduce pain wound Vigilon
Partial and full-thickness Promotes autolytic May macerate Elastogel
wounds debridement periwound; consider Amorphous:
Burns Promotes applying skin sealant Solosite
epithelialization first as protection Intrasite
Adds moisture Requires secondary Normlgel
Minimal to moderate dressing Hypergel
absorption Carrasyn wound gel
Fills dead space
Ease of removal
Hydrofiber (sodium None Moderate to heavy Promotes autolytic Requires secondary Aquacel
carboxymethyl exudative wounds debridement dressing Aquacel-Ag
cellulose) Partial and full-thickness Moderate to marked
wounds absorption
Wound dehiscence Ease of removal
Infected woundsb
Wounds requiring
packing
Alginate None Moderate to heavy Promotes autolytic Requires secondary Kaltostat
exudative wounds debridement dressing Medihoney
Partial and full-thickness Moderate to marked Maxorb extra
wounds absorption Maxorb extra-Ag
Wound dehiscence Ease of removal
Infected woundsb
Wounds requiring
packing
(continued )
DRESSINGS AND PRODUCTS IN PEDIATRIC WOUND CARE 329
Table 2. (Continued)
Barrier None Diaper dermatitis Protects against May be difficult to Stomahesive wafer
Peristomal moisture-associated assess wound with Stomahesive powder
skin damage opaque preparations Coloplast wafer
Protects against Residual cream or Sensicare cream
epidermal stripping ointment should not Criticaid ointment
Protects against be removed prior to White petrolatum
irritation from reapplication Zinc oxide ointment
adhesives Cavilon No-Sting barrier
Marathon
a
Contains starch co-polymer, glycerol, and surfactant and approved for use in full- and partial-thickness wounds, ulcers, skin tears, surgical wounds, and
first- and second-degree burns.
b
Dressings containing silver.
and strategies to prevent these injuries include The use of dressings with soft silicone adhesive
protection of underlying skin, frequent assess- technology has also been associated with signifi-
ments of skin located under the device, and fre- cantly reduced pain during dressing changes.34,35
quent rotation of devices, if possible. Prevention of Choice of an adhesive dressing is dependent on
tracheostomy-related pressure ulcers is aided by several factors, including the need to manage
frequent clinical assessment of the tracheostomy wound exudate, the need to minimize skin trauma
site and by the use of a moisture-reducing and during removal, the need for the dressing to remain
pressure-reducing device interface.20 Simple use of in place in areas of high tension, sustained adhe-
a thin hydrocolloid or thin polyurethane foam un- sion for the duration of the wear time.36 Use of a
der the tracheostomy cannula, securement ties, skin barrier product prior to the application of the
and ventilator connector may also be effective.32 In dressing may also minimize epidermal stripping;
the authors’ experience, use of a polyurethane however, use of a skin protectant under a product
foam dressing with a gentle adhesive such as soft with a soft silicone adhesive may interfere with
silicone is preferred to use of a hydrocolloid dress- dressing adherence. Once epidermal stripping has
ing due to the increased risk of epidermal stripping occurred, management strategies to promote re-
and skin irritation from the adhesive in the hy- epithelialization may include application of barrier
drocolloid dressings and use of a dressing with ointment or cyanoacrylate liquid or application of a
silver is helpful for colonized tracheostomy transparent film dressing.37
wounds. Amorphous hydrogels and silver impreg-
nated dressings have been used in the neonates to Surgical wounds. Surgical wounds are common
treat several types of skin injury, including pres- in the pediatric population, yet there are no clear
sure ulcers.21 guidelines for routine postoperative management
(Fig. 3D). Complications include wound dehiscence
Epidermal stripping. Epidermal stripping is a and infection, which are predictors of poor wound
common form iatrogenic skin injury in neonates healing and other complications. Postoperative
and in any pediatric patient with compromised wound complications are particularly common af-
skin integrity, despite the use of an adhesive re- ter tracheostomy placement, occurring in 29% of
mover prior to removal of adhesive dressings (Fig. patients in one published series.38 Amorphous hy-
3C). In addition, adhesive removal is painful and drogels have been used in the neonatal intensive
often a source of fear and anxiety in the hospital- care unit to treat several types of surgical wounds
ized child. An evaluation of several common skin in the neonatal population, including tracheostomy
dressings, including one using soft silicone adhe- sites.21 In the authors’ experience, use of a hydro-
sive technology, demonstrated the development of gel is also helpful in maintaining a moist wound
epidermal stripping with use of all dressings except environment in neonates with congenital anoma-
the one using a soft silicone adhesive; the use of the lies with exposed mucosa such as cloacal or bladder
dressing with soft silicone adhesive also minimized exstrophy.
transepidermal water loss, a measure of epidermal Surgical site infections occur in 2.5–6.7% of
barrier function.33 In the authors’ experience, use postoperative wounds and are more common in
of products with soft silicone adhesive technology is contaminated and dirty/infected surgical sites.39–41
typically better tolerated by neonates and children Preventing critical colonization and frank infection
with skin fragility or impaired epidermal barrier. of wounds is an important component of postoper-
330 KING ET AL.
Figure 3. Normal skin with intact epidermis, dermis, and subcutaneous tissue (A). Conditions leading to pressure ulcer development include increased
pressure at the surface of the skin in conjunction with shear forces (B). Injury resulting from epidermal stripping (C), surgical wounding (D), moisture-
associated skin damage (E), and intravenous extravasation injury (F). To see this illustration in color, the reader is referred to the web version of this article at
www.liebertpub.com/wound
ative wound care; however, it has been suggested of dressings and skin care incorporating use of
that routine use of a wound dressing after clean honey in neonates have also been published.43 In
surgery has no impact on the development of post- the authors’ experience, some patients may report
surgical wound infections in children.42 In addition stinging with use of medical grade honey products,
to the use of a variety of topical antimicrobial but overall they appear well tolerated and have
agents, specialized dressings with bacteriostatic or been successfully used in the treatment of extrav-
bactericidal properties are also available for the asation injury in neonates and in the management
treatment of colonized and/or infected wounds, in- of pressure ulcers in neonates and children of all
cluding surgical wounds. The most commonly used ages.
antimicrobial agents incorporated into wound Use of wound dressings containing silver as an
dressings are honey and silver ions. antibacterial agent in the management of critically
Honey has been used for centuries in many parts colonized wounds and in the management of burns
of the world for wound management and has sev- has gained popularity in adults; however, use in
eral antimicrobial properties, including high os- children has not received rigorous evaluation.
motic pressure, low pH, high sugar content, and There are several different technologies that in-
production of hydrogen peroxide.43 Several studies volve the incorporation of silver into wound dress-
have documented the efficacy of medical grade ings, including nanocrystalline silver and ionic
honey in augmenting wound healing and addres- silver. Silver ions exert anti-inflammatory and
sing bacterial colonization of wounds in the pedi- antibacterial effects; although nanocrystalline
atric population, in particular in oncology technology appears to provide the lowest risk of
patients.44,45 Although limited, reports on the use toxicity and the highest level of sustained silver
DRESSINGS AND PRODUCTS IN PEDIATRIC WOUND CARE 331
release to the wound, concerns exist regarding their Skin issues related to MASD are common in
safety.46,47 Use in children must take into consid- children with gastrostomy tubes and include gran-
eration concerns for silver toxicity as elevated se- ulation tissue formation, infection, and skin irrita-
rum silver levels have been documented in children tion as a result of leakage.54,55 Use of a hydrocolloid
with burns treated with silver-containing dress- or foam dressing to protect the skin around the
ings.48 Due to these concerns, the authors advocate gastrostomy site may be helpful in minimizing ir-
for judicious use of silver-containing wound care ritation from leakage, although in the authors’ ex-
products in children and for limiting their use to no perience use of a hydrofiber dressing around the
more than two consecutive weeks when possible. gastrostomy is more helpful when there is a signif-
There are several reports in the literature detailing icant amount of drainage due to the limited ab-
use of silver-impregnated dressings in children, sorptive capacity of hydrocolloid dressings. In the
predominantly in burn care.49–51 experience of one of the authors, use of a hydrofiber
Wound dehiscence is a significant risk factor for dressing around the gastrostomy can also help to
postsurgical morbidity and mortality. Risk factors prevent the formation of hypergranulation tissue. A
for wound dehiscence after laparotomy in children barrier ointment such as petrolatum or zinc oxide or
include age less than 1 year, presence of wound a skin-protection powder may be applied to irritated
infection, median incision, and emergency sur- or eroded skin as needed and are also helpful in the
gery.52 A number of different approaches to the management of ileostomy and colostomy site der-
management of wound dehiscence may be consid- matitis.56 The authors find that the application of
ered depending on the size and location of the Stomahesive Protective Powder combined with a
wound and on the presence of infection. Appro- skin barrier product such as 3M Cavilon No Sting
priate wound assessment includes the following: Skin Barrier or Coloplast Brave Skin Barrier Wipe
the depth of the wound; the condition of the wound (‘‘crusting technique’’) followed by application of a
bed including the presence of granulation tissue, barrier ointment is a very effective strategy for the
slough, and/or eschar; the presence of exposed su- management of MASD. Skin protection can also be
tures, hardware, supporting structure (muscle, achieved with use of a cyanoacrylate topical liquid.
bone tendon, and muscle/fascia), or internal or- When dry, these agents create a flexible barrier
gans; the amount and type of drainage; the pres- against moisture, friction, and irritants. In the ex-
ence of odor; the condition of the wound margins; perience of one the authors, they are particularly
the presence of associated pain; and the condi- useful for protection against highly caustic effluent
tion of the periwound skin. Commonly used dress- from high output ostomies, incontinence-associated
ings for the management of wound dehiscence dermatitis in patients with short bowel syndrome,
include alginates, hydrofibers, hydrogels, hydro- and for protection around various feeding and sur-
colloids, and foams, depending on the character- gical tubes such as biliary drains. They are not in-
istics of the wound. In selected patients, use of dicated for use in deep, open wounds; chronic or
NPWT may be considered in the management of nonhealing wounds; second- or third-degree burns;
chronic and/or otherwise complicated surgical or infected wounds.
wounds.
Intravenous extravasation injury. Extravasation
Moisture-associated skin damage. MASD re- injury associated with use of intravenous catheters
sults from prolonged skin exposure to factors such is common in hospitalized children, in particular in
as urine, stool, saliva, mucus, and wound exudate, neonates, and tissue damage and necrosis can re-
which in combination with other factors such as sult in significant scarring and long-term compli-
friction, microorganisms, and chemical irritation, cations (Fig. 3F). For significant extravasation
results in skin inflammation (Fig. 3E).53 Diaper injury in neonates that results in moderate to se-
dermatitis is the most common type of MASD ob- vere swelling, blanching, and pain at the site with
served in the pediatric inpatient population with a skin that is cool to the touch, with or without de-
point prevalence of 24% in one study; a compre- creased or absent distal pulses and evidence of
hensive literature review combined with expert tissue necrosis, the use of an aqueous gel followed
opinion and benchmarking with several large pe- by the application of a hydrofiber sheet covered by
diatric hospitals concluded that the available evi- a hydrocolloid dressing has been suggested as a
dence supports the use of superabsorbent diapers reasonable approach to management.57 Use of a
with frequent diaper changes and routine use of hydrogel dressing or product alone has also been
skin protectants containing petrolatum and/or zinc reported to be effective in the management of ex-
oxide in the perineal area.17 travasation injury.21,58
332 KING ET AL.
FUTURE CONSIDERATIONS
In addition to the promotion of an initiative to ACKNOWLEDGMENTS
develop clinical trials to address the safety and ef- AND FUNDING SOURCES
ficacy of the use of currently marketed wound care The authors have not received funding for this
dressings and products in the neonatal and pedi- work.
DRESSINGS AND PRODUCTS IN PEDIATRIC WOUND CARE 333
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